NR 602 Week 7 iHuman Case 5 Michael Martinez:Pt is an 18 month old child

Michael Martinez – Pediatrics

CC – Cough

Diagnosis – Bronchiolitis by RSV

- Upper respiratory infection, influenza, pneumonia, pharyngitis, group A streptococcus, reactive

airway disease, bronchiolitis

Tests- Rapid Influenza diagnostic test (RIDT), Rapid strep antigen detection test (RST/RADT), Chest x-ray

AP, Respiratory Syncytial Virus (RSV) antigen

Problem Statement:

( Demographic description – chief complaint – Hx and PE key findings – risk factors )

Michael Martinez is a 2 year old boy brought in by his mother with complaint of cough. The mother

states that the cough had started 2 days prior and is productive of yellow sputum, during this same time

the mother reports him having a 102F fever which is ongoing with nasal congestion that has progressed

to difficulty breathing and decreased appetite for the past 5 days. Physical exam shows boggy gray nasal

turbinates, nasal flaring, intercoastal retractions on inspiration and an expiratory wheeze heard in lower

lung fields bilaterally as well as Left submandibular adenopathy. Risk factors include Michael’s father

who is a current smoker. (reduce to 70 words)

CC: Michael Martinez is a 2 year old boy brought in by his mother with complaint of cough.

HPI: The mother states that the cough had started 2 days prior and is productive of yellow sputum,

during this same time the mother reports him having a 102F fever which is ongoing with nasal

congestion that has progressed to difficulty breathing and decreased appetite for the past 5 days.

Meds: Acetaminophen for fever

PMH: Noncontributory

ROS: Only positive findings are seen in HPI

Physical Exam:

VS: Pulse – 110; BP – 100/60 RR – 34; T – 102.0F; SpO2 – 92%

Skin: Skin tenting seen – indicating dehydration

Nose: Nasal turbinates boggy, gray with thick, tenacious yellow drainage bilaterally w/ nasal flaring.

Mouth: Palatine tonsils 2+ with erythema

Lymphatic: Left submandibular adenopathy present

Chest: Intercostal retractions noted., Expiratory wheeze heard on lung auscultation.

ASSESSMENT/PLAN

Test Results:

 Rapid Influenza diagnostic test (RIDT): Negative for Influenza A and B

 Rapid strep antigen detection test (RST/RADT): Negative for Group A streptococcus

 Chest x-ray AP: Hyperinflated lungs – no infiltrates seen.

 Respiratory Syncytial Virus (RSV) antigen: positive

Management Plan

 Place on oxygen (92% sp02 is too low)

 Fluid rehydration – monitor hydration

 Educate parent on what to expect – discharge when stable

 Avoid bronchodialators – has no effect

Questions: none